0001209191-19-006513.txt : 20190201 0001209191-19-006513.hdr.sgml : 20190201 20190201171008 ACCESSION NUMBER: 0001209191-19-006513 CONFORMED SUBMISSION TYPE: 5 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20161231 FILED AS OF DATE: 20190201 DATE AS OF CHANGE: 20190201 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Fontenot Teri G. CENTRAL INDEX KEY: 0001661066 FILING VALUES: FORM TYPE: 5 SEC ACT: 1934 Act SEC FILE NUMBER: 001-12251 FILM NUMBER: 19560662 MAIL ADDRESS: STREET 1: 18933 EAST PINNACLE CIRCLE CITY: BATON ROUGE STATE: LA ZIP: 70634 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: AMERISAFE INC CENTRAL INDEX KEY: 0001018979 STANDARD INDUSTRIAL CLASSIFICATION: FIRE, MARINE & CASUALTY INSURANCE [6331] IRS NUMBER: 752069407 STATE OF INCORPORATION: TX FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 2301 HIGHWAY 190 WEST CITY: DERIDDER STATE: LA ZIP: 70634 BUSINESS PHONE: 337-463-9052 MAIL ADDRESS: STREET 1: 2301 HIGHWAY 190 WEST CITY: DERIDDER STATE: LA ZIP: 70634 5 1 doc5.xml FORM 5 SUBMISSION X0306 5 2016-12-31 0 0 0 0001018979 AMERISAFE INC AMSF 0001661066 Fontenot Teri G. 18933 EAST PINNACLE CIRCLE BATON ROUGE LA 70810 1 0 0 0 Common Stock, par value $0.01 2016-09-23 5 L 0 L 1.18 57.52 A 1074.18 D Common stock, par value $0.01 2016-12-29 5 L 0 L 20.58 62.85 A 1094.76 D The Reporting Person was appointed to the Board of Directors of the Company in January 2016. The Reporting Person placed the shares in a brokerage account with a pre-existing dividend reimbursement plan. Pursuant to this dividend reinvestment plan, the Reporting Person acquired a total of 21.76 shares of Common Stock at a purchase price of $1361.40 during 2016. Reporting of the purchase of these shares was exempt under Rule 16a-6. However, these purchases should have been reported on a Form 5 on or before February 14, 2017. /s/Teri G. Fontenot 2019-02-01